This government document is issued by Department of Juvenile Justice for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://djj.georgia.gov/document/document/conflict-disclosure-and-affidavit/download&sa=U&ved=2ahUKEwj4zr2Z-4yHAxWigP0HHYjsA5k4FBAWegQIBhAB&usg=AOvVaw2ccGx1fOkSNNUIeNVJC7FS&fexp=72519171,72519168